2. An Overview of
Value-Based Modifiers
• Affordable Care Act of 2010 (ACA)
• CMS must bring eRx, PQRS and MU into alignment
• CMS to establish a payment modifier for
differential Physician payments – Remember Pay
for Higher “Value” → Value = Factor (Quality,
Efficiency)
3. An Overview of
Value-Based Modifiers
• ACA → Three Health IT Themes
1. Enhance Quality Reporting and Measurement → Needed
for Reimbursement Reform
→ Expand Quality Reporting (PQRS, ACO Performance Measures,
etc.)
→ Improve Quality of Care (Evidence-Based Guidelines, CDS)
→ Encourage Quality through Reimbursement Modeling (CMMI)
2. Establish Uniform Operating Rules and Standards
3. Promote Health IT Workforce Development
4. An Overview of
Value-Based Modifiers
Driving the linkage between
performance and reimbursement.
5. An Overview of
Value-Based Modifiers
• Builds upon Pilot started 2009 – Resource Use
Reporting to MDs → Feedback Reports
• Added claims-based quality measures
• Resource Use will determine Value Modifier
6. An Overview of
Value-Based Modifiers
• CMS Budget neutral → Some will get
carrots, others will get sticks
PROGRAM 2012 2013 2014 2015 2016 2017
Carrots Carrots / Sticks
CMS Value-Based
+/- +/- +/-
Modifiers None None None
TBD TBD TBD
7. An Overview of
Value-Based Modifiers
• Two established Federal Quality Measure
Programs
• PQRS – Performance on Core Measure Set
• Meaningful Use – EHR Incentive Program
Measures
8. An Overview of
Value-Based Modifiers
• CMS Final Rule – Performance Resource
Measures (11.28.2011)
o VBM → composite of Quality and Costs
o Quality: PQRS and MU used to create 62
preliminary VBM measures for P4P
o Costs: Total per capita costs for target populations
→ COPD, Heart Failure, CAD, and Diabetes
